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Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper

B.R. Celli, W. MacNee, A. Agusti, A. Anzueto, B. Berg, A.S. Buist, P.M.A. Calverley, N. Chavannes, T. Dillard, B. Fahy, A. Fein, J. Heffner, S. Lareau, P. Meek, F. Martinez, W. McNicholas, J. Muris, E. Austegard, R. Pauwels, S. Rennard, A. Rossi, N. Siafakas, B. Tiep, J. Vestbo, E. Wouters, R. ZuWallack
European Respiratory Journal 2004 23: 932-946; DOI: 10.1183/09031936.04.00014304
B.R. Celli
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W. MacNee
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A. Agusti
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A. Anzueto
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B. Berg
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A.S. Buist
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P.M.A. Calverley
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N. Chavannes
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T. Dillard
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B. Fahy
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A. Fein
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J. Heffner
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S. Lareau
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P. Meek
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F. Martinez
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W. McNicholas
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J. Muris
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E. Austegard
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R. Pauwels
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S. Rennard
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A. Rossi
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N. Siafakas
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B. Tiep
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J. Vestbo
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E. Wouters
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R. ZuWallack
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Figures

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  • Fig. 1.—
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    Fig. 1.—

    Algorithm for pharmacological treatment of chronic obstructive pulmonary disease (COPD). SA-BD: short-acting bronchodilator; LA-BD: long-acting bronchodilator; ICS: inhaled corticosteroid. Assess effectiveness by treatment response criteria. If forced expiratory volume <50% predicted and exacerbations of COPD requiring a course of oral corticosteroid or antibiotic occurred at least once within the last year, consider adding regular ICS. Always ensure the patient can use an inhaled device effectively and understands its purpose. If an ICS and a long-acting β‐agonist are used, prescribe a combination inhaler.

  • Fig. 2.—
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    Fig. 2.—

    A flow chart for prescribing long-term oxygen therapy (LTOT). Pa,O2: arterial oxygen tension; Sa,O2: arterial oxygen saturation; ABG: arterial blood gases.

  • Fig. 3.—
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    Fig. 3.—

    Algorithm for pre-operative testing for lung resection. DL,CO: carbon dioxide diffusing capacity of the lung; FEV1: forced expiratory volume in one second; ppo: predicted postoperative; V′O2,max: maximum oxygen consumption.

  • Fig. 4.—
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    Fig. 4.—

    Schematic algorithm from the National Emphysema Therapy Trial for Lung Volume Reduction Surgery (LVRS) (see text). FEV1: forced expiratory volume in one second; DL,CO: carbon dioxide diffusing capacity of the lung. Modified from 69.

  • Fig. 5.—
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    Fig. 5.—

    Algorithm to correct hypoxaemia in an acutely ill chronic obstructive pulmonary disease patient. ABG: arterial blood gas; Pa,O2: arterial oxygen tension; O2: oxygen; Sa,O2: arterial oxygen saturation; Pa,CO2: arterial carbon dioxide tension; NPPV: noninvasive positive pressure ventilation.

  • Fig. 6.—
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    Fig. 6.—

    Flow-chart for the use of noninvasive positive pressure ventilation (NPPV) during exacerbation of chronic obstructive pulmonary disease (COPD) complicated by acute respiratory failure. MV: mechanical ventilation; Pa,CO2: arterial carbon dioxide tension.

  • Fig. 7.—
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    Fig. 7.—

    Continuum of care for chronic obstructive pulmonary disease (COPD). FEV1: forced expiratory volume in one second.

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    Fig. 8.—

Tables

  • Figures
  • Table 1

    Spirometric classification of chronic obstructive pulmonary disease (COPD)

    SeverityPostbronchodilator FEV1/FVCFEV1 % pred
    At risk#>0.7≥80
    Mild COPD≤0.7≥80
    Moderate COPD≤0.750–80
    Severe COPD≤0.730–50
    Very severe COPD≤0.7<30
    • FEV1: forced expiratory volume in one second

    • FVC: forced vital capacity

    • #: patients who smoke or have exposure to pollutants, have cough, sputum or dyspnoea

  • Table 2

    Risk factors for chronic obstructive pulmonary disease

    Host factorsExposures
    Genetic factorsSmoking
    SexSocio-economic status
    Airway hyperreactivity, IgE and asthmaOccupation
    Environmental pollution
    Perinatal events and childhood illness
    Recurrent bronchopulmonary infections
    Diet
    • Ig: immunoglobulin

  • Table 3

    Differential diagnosis of chronic obstructive pulmonary disease (COPD)

    DiagnosisSuggestive features
    COPDMid-life onset
    Slowly progressing symptoms
    Long history of smoking
    AsthmaEarly onset
    Varying symptoms
    Symptoms during the night/early morning
    Presence of allergy, rhinitis and/or eczema
    A family history
    Airflow limitation that is largely reversible
    Congestive heart failureFine basilar crackles on auscultation
    Dilated heart on chest radiography
    Pulmonary oedema
    Volume restriction not airflow limitation on pulmonary function tests
    BronchiectasisLarge volume of purulent sputum
    Commonly associated with bacterial infection
    Coarse crackles/clubbing on auscultation
    Bronchial dilation and bronchial wall thickening on chest radiography/CT
    TuberculosisOnset at all ages
    Lung infiltrate on chest radiography
    Microbiological confirmation
    High local prevalence of tuberculosis
    Obliterative bronchiolitisYounger onset and in nonsmokers
    History of rheumatoid arthritis/fume exposure
    Hypodense areas on expiration on CT suggestive of bronchiolitis
    Diffuse panbronchiolitisEffects mostly male nonsmokers
    Almost all have chronic sinusitis
    Diffuse small centrilobular nodular opacities and hyperinflation on chest radiography and HRCT
    • CT: computed tomography

    • HRCT: high resolution computed tomography

  • Table 4

    Key points of the Treating Tobacco Use and Dependence guidelines

    Tobacco dependence is a chronic condition that warrants repeated treatment until long-term or permanent abstinence is achieved
    Effective treatments for tobacco dependence exist and all tobacco users should be offered these treatments
    Clinicians and healthcare delivery systems must institutionalise the consistent identification, documentation and treatment of every tobacco user at every visit
    Brief tobacco dependence intervention is effective and every tobacco user should be offered at least brief intervention
    There is a strong dose-response relationship between the intensity of tobacco dependence counselling and its effectiveness
    Three types of counselling were found to be especially effective: practical counselling, social support as part of treatment and social support arranged outside treatment
    Five first-line pharmacotherapies for tobacco dependence are effective: bupropion SR, nicotine gum, nicotine inhaler, nicotine nasal spray and nicotine patch, and at least one of these medications should be prescribed in the absence of contraindications
    Tobacco-dependence treatments are cost effective relative to other medical and disease prevention interventions
  • Table 5

    Effect of commonly used medications on important clinical outcomes in chronic obstructive pulmonary disease

    FEV1Lung volumeDyspnoeaHRQoLAEExercise enduranceDisease modifier by FEV1MortalitySide-effects
    Short-acting β‐agonistsYes (A)Yes (B)Yes (A)NANAYes (B)NANASome
    Ipratropium bromideYes (A)Yes (B)Yes (A)No (B)Yes (B)Yes (B)NoNASome
    Long-acting β‐agonistsYes (A)Yes (A)Yes (A)Yes (A)Yes (A)Yes (B)NoNAMinimal
    TiotropiumYes (A)Yes (A)Yes (A)Yes (A)Yes (A)Yes (B)NANAMinimal
    Inhaled corticosteroidsYes (A)NAYes (B)Yes (A)Yes (A)NANoNASome
    TheophyllineYes (A)Yes (B)Yes (A)Yes (B)NAYes (B)NANAImportant
    • FEV1: forced expiratory volume in one second

    • HRQoL: health-related quality of life

    • AE: exacerbation of COPD

    • NA: evidence not available

    • GOLD grade levels are indicated in brackets (see text for explanation)

  • Table 6

    Factors associated with favourable or unfavourable outcome in classical bullectomy

    ParameterFavourableUnfavourable
    ClinicalRapid progressive dyspnoea despite maximal medical therapyOlder age
    Ex-smokerCo-morbid illness
    Cardiac disease
    Pulmonary hypertension
    >10% weight loss
    Frequent respiratory infections
    Chronic bronchitis
    PhysiologicalNormal FVC or slightly reducedFEV1 <35% pred
    FEV1 >40% predLow trapped gas volume
    Little reversibilityDecreased DL,CO
    High trapped lung volume
    Normal or near normal DL,CO
    Normal Pa,O2 and Pa,CO2
    Imaging
     CXRBulla >1/3 hemithoraxVanishing lung syndrome
    Poorly defined bullae
     CTLarge and localised bulla with vascular crowding and normal pulmonary parenchyma around bullaMultiple ill-defined bullae in underlying lung
     AngiographyVascular crowding with preserved distal vascular branchingVague bullae; disrupted vasculature elsewhere
     Isotope scanWell-localised matching defect with normal uptake and washout for underlying lungAbsence of target zones, poor washout in remaining lung
    • CXR: chest radiography

    • CT: computed tomography

    • FVC: forced vital capacity

    • FEV1: forced expiratory volume in one second

    • DL,CO: carbon monoxide diffusing capacity of the lung

    • Pa,O2; arterial oxygen tension

    • Pa,CO2; arterial carbon dioxide tension

    • Table modified from 68

  • Table 7

    Disease-specific guidelines for candidate selection for lung transplantation in chronic obstructive pulmonary disease patients

    FEV1 ≤25% pred (without reversibility) and/or
    Resting room air Pa,CO2 >7.3 kPa (55 mmHg) and/or
    Elevated Pa,CO2 with progressive deterioration requiring long-term oxygen therapy
    Elevated pulmonary arterial pressure with progressive deterioration
    • FEV1: forced expiratory volume in one second

    • Pa,CO2: arterial carbon dioxide tension

  • Table 8

    Clinical history, physical findings and diagnostic procedures in patients with exacerbation of chronic obstructive pulmonary disease (COPD)

    Level ILevel IILevel III
    Clinical history
     Co-morbid conditions#+++++++
     History of frequent exacerbations+++++++
     Severity of COPDMild/moderateModerate/severeSevere
    Physical findings
     Haemodynamic evaluationStableStableStable/unstable
     Use accessory respiratory muscles, tachypnoeaNot present+++++
     Persistent symptoms after initial therapyNo+++++
    Diagnostic procedures
     Oxygen saturationYesYesYes
     Arterial blood gasesNoYesYes
     Chest radiographNoYesYes
     Blood tests¶NoYesYes
     Serum drug concentrations+If applicableIf applicableIf applicable
     Sputum gram stain and cultureNo§YesYes
     ElectrocardiogramNoYesYes
    • +: unlikely to be present

    • ++: likely to be present

    • +++: very likely to be present

    • #: the more common co-morbid conditions associated with poor prognosis in exacerbations are congestive heart failure, coronary artery disease, diabetes mellitus, renal and liver failure

    • ¶: blood tests include cell blood count, serum electrolytes, renal and liver function

    • +: serum drug concentrations, consider if patients are using theophylline, warfarin, carbamezepine, digoxin

    • §: consider if patient has recently been on antibiotics

  • Table 9

    Indications for hospitalisation of patients with a COPD exacerbation

    The presence of high-risk co-morbid conditions, including pneumonia, cardiac arrhythmia, congestive heart failure, diabetes mellitus, renal or liver failure
    Inadequate response of symptoms to outpatient management
    Marked increase in dyspnoea
    Inability to eat or sleep due to symptoms
    Worsening hypoxaemia
    Worsening hypercapnia
    Changes in mental status
    Inability of the patient to care for her/himself (lack of home support)
    Uncertain diagnosis
    Inadequate home care
  • Table 10

    Level I: outpatient treatment

    Patient education
     Check inhalation technique
     Consider use of spacer devices
    Bronchodilators
     Short-acting β2‐agonist# and/or ipratropium MDI with spacer or hand-held nebuliser as needed
     Consider adding long-acting bronchodilator if patient is not using one
    Corticosteroids (the actual dose may vary)
     Prednisone 30–40 mg orally·day−1 for 10–14 days
     Consider using an inhaled corticosteroid
    Antibiotics
     May be initiated in patients with altered sputum characteristics+
     Choice should be based on local bacterial resistance patterns
     Amoxicillin/ampicillin¶, cephalosporins
     Doxycycline
     Macrolides§
     If the patient has failed prior antibiotic therapy consider:
      Amoxicillin/clavulanate
      Respiratory fluoroquinolonesƒ
    • MDI: metered-dose inhaler

    • #: salbutamol (albuterol), terbutaline

    • +: purulence and/or volume

    • ¶: depending on local prevalence of bacterial β‐lactamases

    • §: azithromycin, clarithromycin, dirithromycin, roxithromycin

    • ƒ: gatifloxacin, levofloxacin, moxifloxacin

  • Table 11

    Level II: treatment for hospitalised patient

    Bronchodilators
     Short-acting β2‐agonist and/or
     Ipratropium MDI with spacer or hand-held nebuliser as needed
    Supplemental oxygen (if saturation <90%)
    Corticosteroids
     If patient tolerates, prednisone 30–40 mg orally·day−1 for 10–14 days
     If patient can not tolerate oral intake, equivalent dose i.v. for up to 14 days
     Consider using inhaled corticosteroids by MDI or hand-held nebuliser
    Antibiotics (based on local bacteria resistance patterns)
     May be initiated in patients that have a change in their sputum characteristics#
     Choice should be based on local bacteria resistance patterns
     Amoxicillin/clavulanate
     Respiratory fluoroquinolones (gatifloxacin, levofloxacin, moxifloxacin)
     If Pseudomonas spp. and/or other Enterobactereaces spp. are suspected, consider combination therapy
    • MDI: metered-dose inhaler

    • #: purulence and/or volume

  • Table 12

    Level III: treatment in patients requiring special or intensive care unit

    Supplemental oxygen
    Ventilatory support
    Bronchodilators
     Short-acting β2‐agonist (salbutamol (albuterol)) and ipratropium MDI with spacer, two puffs every 2–4 h
     If the patient is on the ventilator, consider MDI administration
     Consider long-acting β‐agonist
    Corticosteroids
     If patient tolerates oral medications, prednisone 30–40 mg orally·day−1 for 10–14 days
     If patient cannot tolerate, give the equivalent dose i.v. for up to 14 days
     Consider using inhaled corticosteroids by MDI or hand-held nebuliser
    Antibiotics (based on local bacteria resistance patterns)
     Choice should be based on local bacteria resistance patterns
     Amoxicillin/clavulanate
     Respiratory fluoroquinolones (gatifloxacin, levofloxacin, moxifloxacin)
     If Pseudomonas spp. and/or other Enterobactereaces spp. are suspected, consider combination therapy
    • MDI: metered-dose inhaler

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Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper
B.R. Celli, W. MacNee, A. Agusti, A. Anzueto, B. Berg, A.S. Buist, P.M.A. Calverley, N. Chavannes, T. Dillard, B. Fahy, A. Fein, J. Heffner, S. Lareau, P. Meek, F. Martinez, W. McNicholas, J. Muris, E. Austegard, R. Pauwels, S. Rennard, A. Rossi, N. Siafakas, B. Tiep, J. Vestbo, E. Wouters, R. ZuWallack
European Respiratory Journal Jun 2004, 23 (6) 932-946; DOI: 10.1183/09031936.04.00014304

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Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper
B.R. Celli, W. MacNee, A. Agusti, A. Anzueto, B. Berg, A.S. Buist, P.M.A. Calverley, N. Chavannes, T. Dillard, B. Fahy, A. Fein, J. Heffner, S. Lareau, P. Meek, F. Martinez, W. McNicholas, J. Muris, E. Austegard, R. Pauwels, S. Rennard, A. Rossi, N. Siafakas, B. Tiep, J. Vestbo, E. Wouters, R. ZuWallack
European Respiratory Journal Jun 2004, 23 (6) 932-946; DOI: 10.1183/09031936.04.00014304
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  • Article
    • Background
    • Definition of COPD
    • Diagnosis of COPD
    • Epidemiology, risk factors and natural history of COPD
    • Pathology and pathophysiology in COPD
    • Clinical assessment, testing and differential diagnosis of COPD
    • Smoking cessation
    • Management of stable COPD: pharmacological therapy
    • Management of stable COPD: long-term oxygen therapy
    • Management of stable COPD: pulmonary rehabilitation
    • Management of stable COPD: nutrition
    • Management of stable COPD: surgery in and for COPD
    • Management of stable COPD: sleep
    • Management of stable COPD: air-travel
    • Exacerbation of COPD: definition, evaluation and treatment
    • Exacerbation of COPD: inpatient oxygen therapy
    • Exacerbation of COPD: assisted ventilation
    • Ethical and palliative care issues in COPD
    • Integrated disease management for primary care in COPD
    • Conclusions
    • References
  • Figures & Data
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